ROUEN, FRANCE — Congestive heart failure (CHF) brought one in four patients back to the hospital within a year of transcatheter aortic-valve implantation (TAVI) for severe aortic stenosis, a new study shows[1].
Most of these patients (63.6%) returned just once, but 15.9% were readmitted twice for CHF, 15.1% thrice, and 5.3% four times or more.
"We need to treat and follow these patients more carefully than we do, that is the first message," study author Dr Eric Durand (Rouen University Hospital-Charles Nicolle, France) told theheart.org | Medscape Cardiology. "Also, readmission for congestive heart failure is more frequent than we think."
The consequences of this CHF bounce-back after TAVI were obvious and severe. Overall mortality rate was 1.9% at 1 month, 13.7% at 1 year, and 31.4% after a mean follow-up of 27.2 months in the 546 consecutive high-risk patients.
A CHF readmission, however, was associated with roughly double the mortality at 1 year (24.2% vs 10.4%; P<0.001) and at the end of follow-up (50.0% vs 25.6%; P<0.001).
Further, patients with multiple readmissions for CHF had the highest rates of total and cardiac mortality (both P<0.001).
The study, published in the December 11, 2017 issue of JACC: Cardiovascular Interventions, is the first to report the impact of CHF readmission on mortality after TAVI, according to the investigators.
Predictors for CHF-Related Readmissions
Durand and colleagues examined data from 546 patients (mean age 83.9 years) treated at a single center from January 2010 to December 2014 with TAVI using balloon-expandable valves (88.3% Sapien XT, Edwards LifeSciences), preferentially via a transfemoral approach (87.8%).
Their mean logistic EuroSCORE was 15.6%, and 46.5% had been hospitalized for acute HF.
After 1 year, 52.2% of patients had been readmitted at least once, with CHF the culprit in 24.1%.
The high all-cause readmission rate was surprising, Durand said, with prior studies reporting rates of 30% to 45% after TAVI.
Cardiac deaths accounted for 71.9% of total mortality in patients readmitted for CHF vs only 18.6% in patients without such readmissions.
"The high readmission rates remind us that although aortic-valve intervention improves survival at 1 year and quality of life in the vast majority of patients, many continue to struggle with CHF as well as a myriad of other medical conditions," Dr George Hanzel (William Beaumont Hospital, Royal Oak, MI) writes in a related editorial[2].
In multivariate analysis, independent predictors for CHF readmission at 1 year were:
Low aortic mean gradient (hazard ratio [HR] 0.88, P=0.03).
Post-TAVI blood transfusion (HR 2.27, P=0.009).
Increased post-TAVI left atrial diameter (HR 1.47, P=0.02).
Severe post-TAVI pulmonary hypertension (HR 1.04, P<0.0001).
"The predictive factors are not very good; we found four predictive factors, but three of them are post-TAVI and we can't anticipate these patients," Durand said.
Notably, left ventricular ejection fraction and paravalvular aortic regurgitation were associated with higher rates of CHF readmission in univariate analysis but fell out in multivariate analysis. The latter is "somewhat surprising" since aortic regurgitation has been shown to predict repeat hospitalization in prior studies, Hanzel points out in the editorial.
Asked about the finding, Durand explained, "We are not going to do a patient with aortic stenosis with TAVI if we know they have another comorbidity that we can't treat. So it's logical."
The editorial also highlights a new staging classification proposed for severe aortic stenosis based on the extent of cardiac damage on echocardiography prior to valve replacement.[3] In it, stage I reflects left ventricular damage, stage II left atrial or mitral-valve damage, stage III pulmonary vascular or tricuspid-valve damage, and stage IV right ventricular damage.
"It is intriguing that three of the four independent predictors correspond with stages I, II, and III cardiac damage in this proposed schema," Hanzel writes.
"I think it's interesting because it's logical," Durand said of the schema. "But it is difficult to say if a patient has pulmonary hypertension or has a low gradient that we are not going to treat them because potentially they could be readmitted for heart failure. Although probably we need to use more precise echocardiographic or MRI parameters in patients who are borderline or who we are hesitant will improve with TAVI."
The authors suggest that classification of pulmonary hypertension by right heart catheterization could also help heart teams choose the best option to treat and monitor patients with pulmonary hypertension before TAVI.
Finally, further efforts should be made to enhance postdischarge care. Patients readmitted for CHF were significantly more likely to be treated with loop diuretics, beta-blockers, and anticoagulant agents, "but only half of patients were treated with loop diuretics during follow-up, so that's a problem," Durand said.
Durand reports receiving lecture fees from Edwards Lifesciences. Disclosures for the coauthors are listed in the paper. Hanzel reports serving as a proctor for Boston Scientific.
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Medscape Medical News © 2017
Cite this: Post-TAVI Heart-Failure Readmissions Common, Hard to Predict - Medscape - Dec 13, 2017.
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